C. Everett Koop's two terms as U.S. Surgeon General
coincided with the rise of the AIDS epidemic in the United
States, an epidemic that, scientists and health officials
predicted, would turn into the greatest public health
catastrophe of the twentieth century. After his superiors
relegated him to the sidelines of the AIDS debate during
his first four years in office, Koop dedicated almost all
of his time and energy to the disease in his second term.
In 1986, he was finally authorized to issue a Surgeon
General's report on AIDS. In 1988, he mailed a
congressionally-mandated information brochure on AIDS to
every American household. As he recollected, during this
period "AIDS took over my life." Through his report and
his many speeches and interviews on AIDS Koop did more than
any other public official to shift the terms of the public
debate over AIDS from the moral politics of homosexuality,
sexual promiscuity, and intravenous drug use, practices
through which AIDS was spread, to concern with the medical
care, economic position, and civil rights of AIDS
sufferers. Similarly, Koop promoted redefining the
prevalent scientific model of the disease, from a contagion
akin to bubonic plague, yellow fever, and other deadly
historic epidemics that required the strongest public
health measures--mandatory testing and quarantine of
carriers--to a chronic disease that was amenable to long-term
management with drugs and behavioral changes.

During the height of Koop's nomination battle, in June
1981, the Centers for Disease Control (CDC) reported five
cases of homosexual men in Los Angeles who were dying from
Pneumocystis carinii pneumonia, a rare form of pneumonia
most often contracted by people with weakened immune
systems. A month later, the CDC reported on twenty-six
young homosexual men recently diagnosed with Kaposi's
sarcoma, an equally rare skin cancer. During his forty-year
career as a surgeon Koop had seen two cases of
Kaposi's sarcoma; twenty-six cases in a single report, he
realized, were the makings of an epidemic disease, a
disease that was destroying the immune system of otherwise
healthy adults, who then succumbed to other, opportunistic
diseases. The disease, which in 1983 was named Acquired
Immune Deficiency Syndrome, or AIDS, was traced the same
year by French and American scientists to a virus, the
Human Immunodeficiency Virus (HIV). Researchers discovered
the means by which AIDS was spread, namely through sexual
intercourse, the sharing of contaminated needles among
intravenous drug users, transfusion of infected blood, and
transmission from pregnant mother to child in utero, during
birth, or during nursing. A blood test to detect
antibodies to HIV and a technique for killing the virus in
blood products were developed in 1985, making the blood
supply once again safe for transfusion, and clotting
factors safe for hemophiliacs. Yet, also by 1985, nearly
12,000 cases of AIDS had been reported in the United
States, and just under 6,000 of those infected had died.
One of those who died that summer was movie star Rock
Hudson, a friend of President Ronald Reagan whose death
drew nationwide attention to the epidemic.

With no cure and no vaccine, educating the public on
how AIDS was transmitted, who was at risk, and how to
protect oneself was the only way left to slow the spread of
the disease. Since this task fell under the mandate of his
office, Koop concluded that "if ever there was a disease
made for a Surgeon General, it was AIDS." Nevertheless,
for the first four years in office, the nation's top health
officer was prevented from addressing the nation's most
urgent health crisis, for reasons he insisted were never
fully clear to him but that were no doubt political.
During the early years of the epidemic, AIDS predominantly
affected people--homosexuals and intravenous drug users--who,
in the view of President Reagan and his domestic
policy advisers, brought the disease upon themselves by
engaging in immoral conduct, and who were in greater need
of moral reform than of new health information or policies.
For two years, Koop was excluded from the Executive Task
Force on AIDS established in 1983 by his immediate
superior, Assistant Secretary of Health Edward Brandt.
Journalists received instructions from Brandt's office in
advance of press conferences that the Surgeon General would
not answer questions about AIDS, and that he was not to be
asked about it. Meanwhile, as AIDS claimed a growing
number of lives and the Reagan administration sponsored
research but otherwise remained silent on the disease,
Americans worried about the possibility of contagion
through casual contact in schools, restaurants, and public
lavatories; politicians called for the mandatory testing
of the entire population and the quarantine of AIDS
patients; and AIDS activists, represented by homosexual
organizations formed during the gay-rights movement of the
1970s, complained that the conservative Reagan
administration was ignoring the epidemic for political
reasons.

Finally, in February 1986, nearly five years after the
outbreak of the epidemic, President Reagan instructed his
Surgeon General to prepare a report on AIDS. Koop went to
work with dispatch. During the next several months he met
with numerous groups and experts involved in the fight
against AIDS, from the National Hemophilia Foundation to
the National Coalition of Black Lesbians and Gays, from
Christian fundamentalists to scientists such as Dr. Anthony
Fauci, leader of AIDS research at the National Institutes
of Health (NIH), to AIDS patients themselves whom he
visited in hospitals around Washington, D.C. Throughout he
remained careful to treat AIDS not as a moral but as a
public health issue, and to preserve his independence from
any of the groups he consulted--as well as from the White
House. Koop drafted the report himself at a stand-up desk
in the basement of his home on the NIH campus, with only a
handful of trusted staff members as advisers, including
Fauci. Concerned that an in-depth review by Reagan's
domestic policy advisers would lead to the removal of
crucial public health information from the report, such as
on condom use, Koop submitted numbered copies of the final
draft to the Domestic Policy Council, which he collected at
the end of the meeting with the explanation that he sought
to prevent leaks of the report to the media. The stratagem
was successful: after little debate and without further
revision Koop released the report at a press conference on
October 22, 1986. Twenty million copies were eventually
distributed to the public by members of Congress, public
health organizations, and Parent-Teacher Associations. In
plain language the 36-page report discussed the nature of
AIDS, its modes of transmission, risk factors for
contracting the disease, and ways in which people could
protect themselves, including use of condoms. It projected that in
1991, 270,000 cases of AIDS would have occurred. The
prediction was too pessimistic, as the total reported cases
of AIDS in the U.S. through 1991 turned out to be 206,000,
a measure of the effectiveness of Koop's AIDS education campaign.
In his remarks
Koop emphasized that since education was the best and only
strategy of prevention against AIDS, and since AIDS was
spread primarily through sex, school children from grade
three onward should receive sex education.

Former liberal critics of Koop were pleasantly
surprised while his erstwhile conservative supporters were
taken aback by the explicit language and the lack of moral
censure in his AIDS report, and above all by Koop's
promotion of sex education in elementary schools. Yet, as
Koop himself saw it, his approach to AIDS was consistent
with his long-standing professional commitments as a
pediatric surgeon, as well as with his religious faith:
"My position on AIDS was dictated by scientific integrity
and Christian compassion. . . . My whole career has been
dedicated to prolonging lives, especially the lives of
people who were weak and powerless, the disenfranchised who
needed an advocate: newborns who needed surgery,
handicapped children, unborn children, people with AIDS."

In his many speeches on AIDS over the next two years
Koop emphasized that the best protection against the
disease was provided by sexual abstinence and monogamy. As
Koop often pointed out to conservatives reluctant to
address AIDS, science and traditional morality reinforced
one another in the prevention of AIDS. But he insisted
that in order to stop the spread of the disease he had to
dispense health advice to all Americans, including those
who engaged in behavior that was in conflict with his
personal moral values, namely extramarital, promiscuous,
and homosexual sex, and drug use. He appealed to Americans
to remain true to their ethic of care and compassion while
decrying discrimination against AIDS carriers in the
workplace, in schools, in housing, and in insurance
policies. He argued for voluntary, confidential testing
because it would encourage those at greatest risk to seek
medical care, while mandatory testing would drive them
underground, would produce many false positives, and would
serve no purpose in the absence of a vaccine or cure. He
considered quarantine of AIDS carriers unconstitutional and
unnecessary from an epidemiological standpoint. Finally,
Koop drew attention to the plight of the growing number of
children who had acquired AIDS from their mothers or
through blood transfusions, as well as to the effect their
disease had on their families, the subject of a workshop
the Surgeon General convened in April 1987.

In May of 1988, Koop sent an eight-page, condensed
version of his AIDS report to all 107,000,000 households in
the United States, the largest mailing in American history
and the first time that the federal government provided
explicit sex information to the public. His report,
speeches, and television appearances did much to change the
public debate on AIDS in the United States and, along with
it, attitudes towards public discussion of sexuality. In
April of 1988, the first condom ad appeared on national
television. By then, analogies between AIDS and the great
epidemic scourges of the past were heard less often; so
were calls for mandatory testing and quarantine of AIDS
carriers, the most rigorous public health measures employed
during past epidemics. Instead, following the lead of the
Surgeon General, physicians, government officials,
politicians, and the public were coming to view AIDS as a
preventable and manageable disease, even if it was not
curable. With the advent of AZT (zidovudine, formerly
called azidothymidine) in 1986, and especially with the
development of a more effective combination of
antiretroviral drugs in the mid-1990s, AIDS in the United
States changed from an epidemic to a chronic disease, with
the focus as much on the long-term medical care and medical
costs, employment opportunities, and civil rights of AIDS
patients as on AIDS education and prevention.